Download Single Membership Application Form

APPLICATION FOR MEMBERSHIP
(Republic of Ireland)
Carlow District Credit Union Limited
Membership Number: . . . . . . . . . . . . . . . . . . .
*Name:.....................................................................
PPSN
*Address:.................................................................
...................................................................................
...................................................................................
Occupation: .............................................................
PPSN Indicator............................................ Y/N
*Date of Birth: . . . . . . . . / . . . . . . . / . . . . . . . .
*Telephone: .............................................................
Day
* = Mandatory Fields
Month
Year
If the applicant is less than five years at the above address, please state the immediate prior address:
........................................................................................
........................................................................................
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I hereby apply for membership of and agree to abide by the rules of the above credit union, and declare that
I am not or have not been a member of any credit union other than those listed as follows:
........................................................................................ Credit Union Limited
........................................................................................ Credit Union Limited
The information given by me on this form is true and correct to the best of my knowledge and belief. I
understand that any false or misleading information given by me in connection with my application for or my
membership with the credit union may result in termination of my membership, apart from any other legal
sanctions that may apply.
I confirm that the account is for my own personal use and benefit .................................................Yes/No
If you ticked No above, please specify the beneficial owner of the account . . . . . . . . . . . . . . . . . . . . . . . . . . .
Applicant’s Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . / . . . . . . . . . . . . . / . . . . .
Day
Month
Year
APPLICATION FOR MEMBERSHIP (contd.)
IN THE EVENT THAT THE APPLICATION FOR MEMBERSHIP IS IN RESPECT
OF A PERSON WHO IS UNABLE TO GIVE RECEIPTS:
I/We apply for membership in the name of the said ...............................................................................and I/we
acknowledge that all shares/deposits arising from this membership now and hereafter shall be his/her sole property and all withdrawals shall be applied to his/her sole benefit.
In the event of the account being opened by more than one person it is required that:
both parties / either party * be present to make withdrawals.
In the event of the account being opened by a person other than a parent/guardian of the member, (insert name
of parent or guardian) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .as parent/guardian * shall be nominated to
give any necessary receipts should the member be unable to do so.
Signed:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parent(s)/Guardian(s)/Other*
Date:
................. / ................./ ................./
Consent to use and disclosure/Data Protection Acts, 1988 and 2003 and Section 71 of the Credit Union Act, 1997
I understand that under the Data Protection Acts, 1988 and 2003 (the “DPA”), my consent may be required for the Credit Union
to process personal data that it may have in its possession concerning me (including disclosure to third parties). I note that this
personal data may include sensitive personal data, such as data about my health, within the meaning of the DPA, the proceedings of which requires my explicit consent.
I also understand that under Section 71 of the Credit Union Act, 1997, the Credit Union, subject to exceptions listed in the
Section, shall not disclose or permit to be disclosed, without my consent, any information that concerns an account or transaction of mine with the Credit Union.
For the purpose of assessing my application for membership, assessing any loan applications which I may make to you and
generally for administering and monitoring any accounts I have with the Credit Union, including any loan accounts I have
from time to time with you:
1. I consent:
(i)
to you seeking information concerning applications for loans and my credit history from the date of my original consent from any credit union and for that purpose you may disclose any relevant information in any loan application
which I make to you or which you may have concerning me to any such credit union;
(ii) to any credit union disclosing information to you concerning applications for loans and my credit history from the date
of my original consent with any such credit union;
(iii) to you disclosing any information in any application (including loan applications) or in respect of any account or
transaction of mine with the Credit Union from the date of my original consent to officers or employees of the Irish
League of Credit Unions for the purpose of fulfilling my requirements and under the Savings Protection Scheme if
such a scheme is operated on behalf of the Credit Union by the Irish League of Credit Unions; and
(iv) to the processing of any information relating to me, either contained in this form or any other form or application, for
the purpose of assessing applications and administering any accounts I maintain with the Credit Union.
*Delete as appropriate
APPLICATION FOR MEMBERSHIP (contd.)
2. From time to time, the Credit Union, or third parties selected by the Credit Union, may use your details to inform
you of goods and/or services which may be of interest to you.
The use of your details for marketing purposes will depend on the preferences that you express below:
Opt-In (Marketing by email or text message)
I consent to the Credit Union informing me of goods or services that may be of interest to me by email,
or text message.
Email address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mobile No: . . . . . . . . . . . . . . . . . . . . . . . . .
Opt-Out (other forms of marketing)
Please tick the box opposite if you do not want the Credit Union, or third parties selected by the Credit
Union, to inform you by phone or letter of goods or services that may be of interest to you.
Please note that you have the right to access personal data held about you by the Credit Union and
to correct any inaccuracies in such data.
Applicant’s Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Print Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . / . . . . . . . . . . . . . / . . . . .
Day
Month
Year
Witnessed by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Print Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The information which is held on the ICB database relates to credit agreements between these ICB members and their
customers/members. A condition of such agreements is that the customer/member agrees that the financial institution/
credit union may use the data supplied for the purpose of credit checking. Consequently, where an individual enters a
credit agreement with an ICB member, details of the individual’s performance in complying with the terms of the agreement are input to the ICB “credit file” database, which may be accessed by all member institutions of ICB. Each time a
person applies for credit from an ICB member, that institution accesses the ICB’s “credit file” to ascertain the applicant’s
performance under any previous credit agreements with ICB members.
3. In addition to paragraphs 1 and 2 above, we further consent to and authorise the Credit Union to process and retain data
provided by us in respect of this application, to seek and provide credit references (searches), to record details of any
transaction relating to a loan or other credit which may result from this application with the Irish Credit Bureau (ICB)
for a period of 5 years from the date of closure of the loan and ICB to record, retain and disclose to its members details
of such searches for a period of one year.
4. I acknowledge that the Credit Union and/or the ICB are permitted to disclose any material mis-statement of fact
contained in the application for financial accommodation to its members and relevant bodies. I consent to any such
application being processed, recorded and retained by ICB.
Please note that you have the right to access personal data held about you by the Credit Union and to correct any inaccuracies in such data.
Applicant’s Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . `
Print Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Print Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . / . . . . . . . . . . . . . / . . . . .
Day
Month
Year
APPLICATION FOR MEMBERSHIP (contd.)
THIS SECTION IS TO BE COMPLETED BY THE CREDIT UNION
Evidence of Identification
(Copies must be attached)
(Complete at least one of the following)
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Current Valid Passport
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Current Valid Driving Licence
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National Identity Card
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Birth Certificate (for a minor/or evidence of name change only)
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Other*
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*Please specify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Evidence of Address Verification (within the last 3 months)
(Copies must be attached)
(Complete at least one of the following)
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Current Utility Bill (e.g. Gas/Electricity Bill)
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Official document from Revenue Commissioners or
Department of Social Protection
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Original Recent Bank/Building Society Statement
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Local Authority Document (e.g. Refuse Collection Bill)
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Current Insurance Document (e.g. House/Motor Insurance)
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Other*
*Please specify i.e. in genuine cases where the above cannot be presented)
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Application approved and details verified in accordance with the standard rules by:
Signed: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date: . . . . . . . . . . . . . . . . . . . . . .
(Membership Committee)
Carlow District Credit Union Ltd. is regulated by the Central Bank of Ireland